Meningitis, Encephalitis, and Sepsis

Meningitis and Encephalitis

Meningitis is one of the most serious infections you can have. It is also
one of the scariest -- understandably, since untreated some forms of
meningitis can cause death or lasting impairment.

The meninges are membranes that enclose the brain and spinal cord.
There are actually three layers of membrane: the "dura", which is a tough
outer layer; the "arachnoid", which is a lacy, web-like middle layer; and
the "pia", which is a delicate, fibrous inner layer containing many of the
blood vessels that feed the brain and cord.

Meningitis, strictly speaking, is an inflammation of the meninges.
(The suffix "-itis" stands for "inflammation".) Encephalitis is
inflammation of the brain tissue itself: "encephal-" refers to the brain
tissue. There are many causes for inflammation of tissue, and
the meninges are no exception. However, the most common cause of meningeal
inflammation is irritation caused by infection with bacteria or viruses.
These organisms usually enter the meninges through the bloodstream from
other parts of the body. Many meningitis-causing bacteria are carried
in the nose and throat, often without the carrier having symptoms.

Viral meningeal infections are usually (but not always) less severe than
bacterial infections. This is quite fortunate, since there are no
antibiotic treatments available for most viruses and we must therefore
let viral meningitis run its course by itself. Bacterial meningitis,
on the other hand, must be treated with antibiotics in most cases to
avoid severe consequences. Unfortunately the only way to confirm that
meningitis is not bacterial is to culture the spinal fluid (actually the
cerebrospinal fluid, since it bathes both the spinal cord and the brain)
and see if there are bacteria in it. This can take 2-5 days.
Since a bacterial meningitis can do a LOT of damage in 2-5 days, we always
start antibiotics immediately after doing the spinal tap and keep giving
the antibiotics until the culture has shown no bacteria for 2-5 days. This
may seem wasteful (especially to bean-counters), but it is far better to
treat all suspected meningitis patients promptly than to have to treat the
long-term consequences of an untreated meningitis.

Since inflammation and resulting swelling seem to be the main cause of
brain damage from meningitis, steroids have been used in some cases to
help lessen the inflammation. Steroids usually are given along with
antibiotics or just before the antibiotics are given, and may not be
appropriate in all cases of meningitis.

Sepsis

"Sepsis" is the term we use for an overwhelming bacterial infection.
Sepsis usually includes "bacteremia", or bacteria in the blood, although
bacteremia can happen without sepsis (you will have bacteria in your blood
briefly every time you brush your teeth...). Usually we reserve the term
"sepsis" for patients whose infections are so severe that they are in
shock; such infections happen more often when the immune system isn't
working quite right (because of cancer, AIDS, malfunctioning organs or
bone marrow, or other diseases). Very young babies do not
have fully-functioning immune systems either and are thus susceptible
to sepsis; this is why we routinely give IV antibiotics to any child
under 2 months old who has a fever -- we cannot risk leaving sepsis
untreated.

Meningococcus is a bacteria often carried in the nose and throat without
symptoms. It can be spread by droplets coughed or sneezed out by an
infected person or by a carrier; many outbreaks of meningococcal infection
occur in people living in close quarters (like schools, colleges, and
military installations). It takes 1-10 days (most often 4 days or less)
after exposure to show symptoms; patients are usually contagious until
they have been treated for at least 24 hours.

Infection with meningococcus can cause meningitis, sepsis, or both. Oddly,
someone with meningococcal infection with meningitis may do better
than s/he would with sepsis and no meningitis; this does not always happen,
though. Signs of meningococcal infection may include fever with chills
and a rash; the classic rash of meningococcal infection is "petechial",
caused by tiny blood clots just below the skin surface. In severe cases
the infection can result in shock and death within a few hours even if treated.
Also, as antibiotics kill the meningococci, the breakdown products of the
dead bacteria can cause inflammation and abnormal blood clotting.
Blood clotting in the wrong places can block blood flow to large parts of
the body, and many patients with meningococcal sepsis lose fingers or toes,
and sometimes hands, feet, or larger parts of their arms or legs, because
of these clots.

In the past meningococcal infection was treated successfully with
penicillin G.
Unfortunately, some strains of meningococcus are resistant
to penicillin G and must be treated with other antibiotics such as the
third-generation
cephalosporins.

There are many different groups or "serotypes" of meningococci, at
least 8 of which can infect people. The most common infectious groups
are labelled A, B, C, X, Y, Z, 29-E, and W-135 (and no, I don't know
exactly how the labels were assigned...). Groups B and C are the groups
most often seen in the United States. Unfortunately we do not yet have
a good vaccine for group B. We do, however, have vaccines that protect
against groups A, C, Y, and W-135.

The Advisory Committee on Immunization Practices and the
Centers for Disease Control and Prevention
now recommend that all children be vaccinated with the new meningococcus
vaccine at age 11 or 12, and (as they have in the past) that all students
entering college be vaccinated against groups A, C, Y, and W-135. The
American Academy of Pediatrics also
recommends that all entering college students get the vaccine, and many
colleges and universities require their new students to be vaccinated.
Travelers to countries where meningococcus is more common should also
receive the vaccine, as should patients whose spleens have been
removed or no longer work properly (such as patients with sickle-cell
anemia, whose spleens eventually fail). Certain groups of people, such
as military personnel, routinely receive the vaccine. Please see my
meningococcus
page for more information on meningococcus and the vaccines.

Pneumococci are even more common than meningococcus; in fact pneumococci
are the most common cause of
ear infections and sinus infections, as well as the most common
bacteria found in the blood of children under 2 years old with fevers,
many of whom have no obvious site of infection. Again, like meningococcus,
many people have pneumococci in their noses and throats but have no symptoms.
The bacteria is transmitted from one person to another, usually by droplets.
Like viral upper respiratory
infections, pneumococcal infections are more common in winter.
Infection can begin as little as 1-3 days after exposure.

The signs of pneumococcal meningitis and sepsis can be the same as those of
meningococcal meningitis. Often, however, pneumococcal infection can appear
first as a high fever with a very high white-blood-cell count (where almost
all of the white cells are neutrophils or bacteria-fighting cells)
and no obvious site of infection.

Again, like meningococcus, pneumococcal infections could be treated
with penicillin
G, but penicillin-G-resistant pneumococci have become
more and more common, especially with antibiotic overuse (this is one
reason why we use so many different antibiotics to treat ear infections).
We usually start meningitis or sepsis treatment with
third-generation
cephalosporins such as ceftriaxone until the cultures have been completed
and we know what antibiotics can be used.

There are over 80 different know serotypes of pneumococcus. Some are
more prevalent in different areas; some are more prevalent in children,
while others are more common in adults. There is a vaccine available
that protects against 23 of the known serotypes; as with meningococcus,
the vaccine is given mainly to those at risk of severe infection,
including those whose spleens no longer work properly. This vaccine does
not provide complete or lifetime protection, does not work well in
infants, and does not necessarily help prevent ear infections.
However, there is a vaccine available that is intended for infants
and children and that, although it only protects against 13 different
serotypes, provides much better immunity. See my
pneumococcus
page for more information.

Haemophilus influenzae B, or HiB, used to be the most common cause
of bacterial meningitis in children, as well as a common cause of
ear infections. That was
before the introduction of vaccines against HiB in the late 1980's. Now we
almost never see HiB meningitis -- another good reason to vaccinate.
See my HiB page for
more information on HiB and the vaccine.

As always, you should talk to your doctor about the vaccines, or about
prophylactic antibiotics, and about their pros and cons before deciding whether
to get them for your children or yourself.

Meningitis can be caused by other bacteria as well, including staphylococcus
(found on everyone's skin) and Escherichia coli (E. coli -- the
major bacteria in stool). Encephalitis can also be caused by several bacteria,
including Bartonella henselae (the bacteria that causes
cat-scratch
disease).

Viral Meningitis and Viral Encephalitis

Although it is quite possible to have an overwhelming viral infection,
generalized viral infections are common enough -- and usually not
dangerous enough -- that we don't often consider viral sepsis as a
separate problem. (Besides, we have no antibiotics to treat most viral
infections, anyway.)

However, viral meningitis is a separate problem, and a common one at that.
We can't treat viral meningitis either, but viral meningitis is usually
less severe and causes less damage than bacterial meningitis. (I had
viral meningitis myself as a teenager. I'm not quite normal, but it doesn't
seem to have done too much damage...) Viral encephalitis, on the
other hand, can do a great deal of damage since it attacks the brain tissue
itself, and is just as untreatable as viral meningitis unless it is caused
by one of the few viruses for which we have antibiotics (such as herpes
simplex).

Many commmon viruses can cause meningitis. Among these are enteroviruses
(like the polio
viruses), varicella (the
chickenpox virus), the
mumps virus,
adenoviruses, and many others. Notice that many of these viruses are
ones we have vaccines for; a child who has been properly immunized against
these viruses will likely not develop meningitis from them.
However, if there is no vaccine for the virus there is no really good way to
prevent meningitis caused by that virus except to stay away from people who
have the virus -- which can be very hard, because a particular virus may
infect hundreds of people but cause meningitis in only 1 or 2 of them.

PLEASE NOTE: As with all of this Web site, I try to give
general answers to common questions my patients and their parents ask me
in my (real) office. If you have specific questions about your
child you must ask your child's regular doctor. No doctor can give
completely accurate advice about a particular child without knowing and
examining that child. I will be happy to try and answer
general questions
about children's health, but unless your child is a regular patient of
mine I cannot give you specific advice.